HospitalInspections.org

Based on observation and staff interview the facility failed to provide confidentiality of clinical records to those patients receiving blood pressure medications and blood pressure monitoring. The facility failed to provide nursing care and service that follow the Professional Standards of Practice.

The findings include:

1. During a medication administration observation conducted on the 200 wing at 9:40 a.m. on 2/14/12 a Technician (Tech) was observed taking a blood pressure on Patient
#4. The Tech told the patient his blood pressure was 102/60 and handed him a small piece of white paper, approximately 3 inches square. Patient #4 brought this piece of paper to the nurse' station and handed it to the nurse. The nurse took the square of paper and placed it on top of her medication cart. Prior to giving Patient #4 his scheduled medication, the nurse asked the Tech, who was standing at the nurse's station, to give her the vital signs sheet. The Tech stated "I will show it to you later" and walked away from the nurse's station. The nurse gave the patient his medication at 9:50 a.m. Upon observation at this time, the square of white paper was noted to state "2/14/12, 9:45 a.m., 102/60." Patient #4's name was also indicated on this square of paper.

Upon interview on 2/14/12 at 10:45 a.m. with the Director of Nursing, Risk Manager and Nursing Supervisor, it was stated that using a square of white paper was not the procedure to be used when recording a patient's blood pressure. At 11:15 a.m. the Director Nursing and Risk Manager acknowledged the proper procedure for recording blood pressures was not being followed and represented a breach of patient confidentiality. They also stated the tech taking the blood pressure did not receive training relating to the recording of blood pressures per the facility plan of correction and quality assurance/performance improvement plan.
Review of the Medication Administration Record, on 2/14/12 at 11:30 a.m., revealed a blood pressure was recorded for Patient #4, as "0950 (9:50 a.m.), 102/60" with the nurse initials indicating that Suboxone, 2 mg/0.5 mg, 2 sublingual films were administered at 10 a.m. on 2/14/12.

2. During a medication administration observation conducted on the 100 wing at 10:00 a.m. on 02/14/12 Patient #10 presented to the medication window with a square piece of paper approximately 3 inches by 3 inches. The paper had a blood pressure reading documented on the paper. The paper included the patient name. The nurse asked the technician for the BP sheet. The technician stated "That will really slow us down, we have patients waiting." An observation through the medication room window revealed two other patients were standing near Patient #10. The other patients were standing on each side of Patient #10 and the piece of paper was face up with the blood pressure reading visible to the other patients. The tech reluctantly brought the VS sheet a few minutes later.
At 11:15 a.m. the Risk Manager (RM) explained the technicians should know better. The Director of Nursing (DON) stated "this is unacceptable." The DON continued to explain the clinical staff were provided inservices regarding the use of the new Vital Sign Information Sheet.

At 2:15 p.m. on 2/14/12 the Nursing Supervisor stated that an inservice had been given to all nurses and technicians on duty at this time, regarding the use of the "Nurse - Tech Vital Sign Information Sheet."

Based on observations, staff interviews, and facility record review the facility failed to provide monitoring of data driven/data gathering for Quality Assurance Performance Improvement (QAPI) program regarding the identified quality indicator for Falls and Blood Pressure (B/P) recording in the facility.

The findings include:
1. A review of the plan of correction regarding the reduction of patient falls was conducted with the Risk Manager Designee and the Risk Manager (RM). The plan of correction documents the falls will be monitored daily, including the evaluation of the patient falls including the evaluation of patient medications at time of fall to improve patient outcomes. This interview and review of the information was conducted on 02/13/12 at approximately 3:50 p.m. The Designee presented the facility document entitled "Incident Report Data January 2012." This document included (not limited to) a grid listing the incident report data. The data notes the number of falls is 8 falls for the 100 and 200 wings. The facility document entitled "Falls Risk Surveillance Conclusion" outlines the approaches and interventions including (not limited to):The housekeepers are continuing to mop according to the new education. There are "wet floor" signs of different models around the facility to test which is the most effective in identifying a freshly mopped floor. A new fiber microfiber mop is being used and appears effective in properly cleaning the floors without leaving a wet residue."

At the time of this review, the CEO was asked about the parameters and thresholds utilized and the data reflecting the thresholds and/or audits for the housekeeping compliance. The CEO returned with a "new facility form" used to monitor the facility infection control issues, environment issues and physical plant issues. The form is not specific to the housekeepers utilizing the wet floor signs or the microfiber mops.

Another surveillance approach documented the outside patio be swept and cleaned by the maintenance staff. This was not monitored or audited to provide compliance data.

2. An interview with the Director of Nursing (DON), Nursing Supervisor and Risk Manager (RM) was conducted at 10:45 a.m. on 2/14/12. They were asked regarding the process for medication administration and the taking of Blood Pressures process. The DON explained there is a new form used for Blood Pressure monitoring and recording. The nursing supervisor then showed the "Vital Sign Sheet Instructions" which includes the form being utilized to record the B/P readings. The DON was informed of the observations by the survey team regarding the square sheets of paper used for the blood pressure reporting to the medication nurse at the Medication window. (Please refer to A-147 for additional information). The DON then stated "This is unacceptable." The DON continued by commenting the staff was trained and in serviced on the process and the vital sign sheets and should be utilizing the current process of documentation. The DON commented the B/P should be taken directly prior to the B/P medication being administered and recorded on the sheet and then the nurse will document on the MAR (Medication Administration Record).
The DON, Nursing Supervisor and the RM returned at 11:11 a.m. and reported the Techs (Technicians) were gathered for an immediate meeting to review the in-service material previously presented and to review the process of taking, documenting and reporting the vital signs to the nurse.
At 11:35 a.m. the Risk Management Designee presented the facility staff member training list. The nurse supervisor confirmed the staff members were trained and commented the ones not trained as per the list are mostly as needed staff and only work sporadically.
At 2:15 p.m. on 2/14/12 the Nursing Supervisor stated an inservice had been given, to all nurses and Techs on duty at this time, regarding the use of the "Nurse - Tech Vital Sign Information Sheet."
A review of the Quality Assurance Audit Tool for Medication Administration contains a threshold regarding the blood pressures. The #8 threshold states "Was the blood pressure checked prior to administering B/P med (medication) or pulse prior to Digoxin and documented on the MAR."
The tracking and trending tool does not adequately provide for monitor the blood pressure documentation with the current process using the facility form entitled " Nurse-Tech Vital Sign Information Sheet."

Based on record review and interview, the facility failed to have documentation in the clinical record indicating the degree and intensity of treatment furnished to Patient # 30 (1 of 4 Patients reviewed for the Special Conditions). The clinical record failed to document treatments being given as outlined in the Plans of Care.

The findings include:

On 2/13/12 at about 9:30 a.m., a review of the clinical record for Patient # 30 was conducted. Patient was admitted on 2/1/12 with a diagnosis of "Signs and symptoms of Bipolar Mood disorder and increased alcohol use to cope. Medically patient suffers from seizures."

A review of a Treatment Plan #1 for "Mood Instability/Bipolar Disorder/Altered Thoughts" revealed the following short term goals/objectives:
2/1/12 - Patient will utilize educational materials provided by staff in order to learn about their illness and complete exercises in handouts. Treatment to be delivered by the Therapist 1 x/week for 4 weeks.
2/1/12 - Patient will identify 3 signs and/or symptoms of hypomania and/or a manic episode or depressive episode. Treatment to be delivered by Therapist 1 x/week for 60 minutes each treatment.
2/1/12 - Patient will verbalize 10 ways bipolar/thought disorder has affected their use of alcohol or other drugs and 10 ways their use of alcohol or other drugs has affected their bipolar/altered thought disorder. Treatment by Therapist during primary group 1 x week for 1 hour for 4 weeks.
2/1/12 - Patient will list 10 symptoms of mania that they miss the most in present in group. - Therapist in primary group 1 x week for 1 hour.
2/1/12 - Patient will identify and verbalize 10 symptoms of mania depression or altered thoughts that are most distressing. Treatment by Therapist 1 x week for 1 hour.
2/1/12 - Patient will develop a prevention plan with identified triggers, alternative ways to cope and supportive aftercare treatment. Treatment by Therapist 1 x week for 1 hour.
2/1/12 - Patient's symptoms of Bipolar Mood Disorder; Chemical Dependency; ADHD will be addressed through medication management and education. Treatment by Physician daily for the duration of treatment.

A review of a Treatment Plan #2 for "Alcohol Dependency and Detox" revealed the following short term goals/objectives:
2/1/12 - Patient will identify and verbalize in Primary Group:
1. 10 triggers that cause him/her to use alcohol
2. 10 coping strategies to block triggers in using alcohol
3. 20 clean and sober activities to participate in after discharge
These will be addressed in Primary Group daily for 60 minutes.
2/12/12 Patient will complete and verbalize a discharge plan that supports a clean/sober lifestyle in discharge planning group. Discharge Planning Group 1 x week for 1 hour.

On 2/13/12 at about 11:30 a.m., a review of the documentation related to actual treatments/groups attended revealed the following:
2/2/12 - Therapist Group Notes - "Absent" from group 1 and group 2. Reason given "Detox."
2/3/12 - Therapist Group Notes - Morning group's are blank. Afternoon group 2 attended
2/3/12 - Activity Therapy Daily Participation Log - Activity - Aquatics
2/4/12 - Therapist Group Notes - "Absent" without any explanation.
2/4/12 - Activity Therapy Daily Participation Log - Activity - Volleyball
2/5/12 - Therapist Group Notes - "Absent" without any explanation.
2/5/12 - Activity Therapy Daily Participation Log - Activity - Volleyball
2/8/12 - Activity Therapy Daily Participation Log - Activity - Aquatics
2/8/12 - Activity Therapy Daily Participation Log - Arts and Crafts
2/9/12 - Activity Therapy Daily Participation Log - Arts and Crafts
2/11/12 - Activity Therapy Daily Participation Log - Activity - Aquatics
2/11/12 - Activity Therapy Daily Participation Log - Activity - Volleyball
2/11/12 - Therapist Group Notes - Afternoon groups blank.
2/12/12 - Therapist Group Notes - Morning notation "Absent" without any explanation. Afternoon groups blank.

Documentation for Patient #30 revealed he attended activities such as aquatics, volleyball, arts & crafts but failed to attend most group meetings.

Documentation for each goal/objective that had been Care Planned for Patient # 30 was not documented.

During an interview with the Medical Director on 2/13/12 at about 3:30 p.m. he agreed the documentation in the clinical record failed to demonstrate degree and intensity of treatments.

Based on record reviews and interview, the facility failed to have complete psychiatric evaluations for 3 (Patients # 30, #31 and #32) of 4 records reviewed for the Special Conditions. The clinical record lacks documentation of the "onset of illness and circumstances leading to admission."

The findings include:

On 2/13/12, clinical record reviews were completed for Patients #30, #31, and #32.
A review of the psychiatric evaluation by the treating physician failed to address the "onset of illness" and the "circumstances leading to admission" as required.

The lack of this information makes it impossible to determine how long the patient has been ill; if it was gradual or sudden onset; if it is a recurrence; were there precipitating factors; what symptoms, signs, behaviors made this hospitalization necessary; what treatment has the patient already received before coming to the hospital?

During an interview with the Medical Director on 2/13/12 at about 3:30 p.m., he concurred this information was missing from these records.